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Breast in association with a ventriculoperitoneal shunt: An unexpected discovery

Roisin M. Heaney, Patricia Cronin, Maurice Stokes

ABSTRACT Introduction: Breast cancer and ventriculoperitoneal (VP) shunts are independently, relatively common entities. However, the development of cancer in the presence of a shunt catheter is a rare occurrence. Case Report: A 75-year-old female presented with multifocal invasive lobular in association with a ventriculoperitoneal shunt. The patient did not include insertion of a VP shunt in her medical history during the initial consultation and this in conjunction with the absence of the shunt catheter on preoperative imaging resulted in the unexpected discovery of the VP shunt adjacent to the tumour intra-operatively. Meticulous dissection allowed for preservation of the VP shunt and the patient had an unremarkable recovery. Conclusion: Preoperatively, a thorough history is essential for the safe provision of patient care. Neurosurgeons must give due consideration to the possibility of future oncological breast when planning insertion of a ventriculoperitoneal shunt.

International Journal of Case Reports and Images (IJCRI) International Journal of Case Reports and Images (IJCRI) is an international, peer reviewed, monthly, open access, online journal, publishing high-quality, articles in all areas of basic medical sciences and clinical specialties.

Aim of IJCRI is to encourage the publication of new information by providing a platform for reporting of unique, unusual and rare cases which enhance understanding of disease process, its diagnosis, management and clinico-pathologic correlations.

IJCRI publishes Review Articles, Case Series, Case Reports, Case in Images, Clinical Images and Letters to Editor.

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CASEcase REPORTreport Peer Reviewed OPEN| OPEN ACCESS ACCESS Breast cancer in association with a ventriculoperitoneal shunt: An unexpected discovery

Roisin M. Heaney, Patricia Cronin, Maurice Stokes

Abstract How to cite this article

Introduction: Breast cancer and Heaney RM, Cronin P, Stokes M. Breast cancer ventriculoperitoneal (VP) shunts are in association with a ventriculoperitoneal shunt: independently, relatively common entities. An unexpected discovery. Int J Case Rep Images However, the development of cancer in the 2015;6(12):763–766. presence of a shunt catheter is a rare occurrence. Case Report: A 75-year-old female presented with multifocal invasive lobular carcinoma in doi:10.5348/ijcri-2015123-CR-10584 association with a ventriculoperitoneal shunt. The patient did not include insertion of a VP shunt in her medical history during the initial consultation and this in conjunction with the absence of the shunt catheter on preoperative INTRODUCTION imaging resulted in the unexpected discovery of the VP shunt adjacent to the tumour intra- Breast cancer is an increasingly common phenomenon operatively. Meticulous dissection allowed for worldwide. In Ireland, 1 in 9 women developing the preservation of the VP shunt and the patient disease throughout their lifetimes [1]. Insertion of a had an unremarkable recovery. Conclusion: ventriculoperitoneal (VP) shunt is the primary treatment Preoperatively, a thorough history is essential for for adult and paediatric hydrocephalus [2, 3] and remains the safe provision of patient care. Neurosurgeons one of the most commonly performed neurosurgical must give due consideration to the possibility of procedures [4]. While these are two relatively common future oncological breast surgery when planning entities, the occurrence of breast cancer in the presence insertion of a ventriculoperitoneal shunt. of a VP shunt is a very rare event. To date only five cases have been documented in literature. Keywords: Breast, Cancer, Mastectomy, Ventric- uloperitoneal shunt CASE REPORT

A 75-year-old female was referred to a symptomatic breast clinic with a three-month history of right sided Roisin M. Heaney1, Patricia Cronin1, Maurice Stokes1 mastalgia. Her past medical history was notable Affiliations: 1Breast Health, Mater Misericordiae University for hypertension, obesity, atrial fibrillation and an Hospital, Dublin 7, Ireland. intracerebral hemorrhage nine years previously. Risk Corresponding Author: Roisin M. Heaney, Breast Health, factors for breast cancer included advanced age and late Mater Misericordiae University Hospital, Eccles Street, menopause. Clinical examination was unremarkable and Dublin 7, Ireland; Tel: 3531 803 2560; Fax: 3531 8032369; a VP shunt was not palpable. Mammography, however, Email: [email protected] revealed two small areas of calcification in the right breast, one at the 3 o’clock and the other at the 12 o’clock position, Received: 09 September 2015 as well as an area of calcification in the left breast. An Accepted: 09 October 2015 ultrasound guided biopsy was performed and histology Published: 01 December 2015 revealed invasive lobular carcinoma at both sites in the

International Journal of Case Reports and Images, Vol. 6 No. 12, December 2015. ISSN – [0976-3198] Int J Case Rep Images 2015;6(12):763–766. Heaney et al. 764 www.ijcasereportsandimages.com right breast and high grade DCIS in the left breast. The VP shunt was not visualized on mammogram or ultrasound (Figure 1). Following discussion at a multidisciplinary meeting, she proceeded to bilateral mastectomy and (SLN) biopsy. Intraoperatively, the VP shunt was encountered unexpectedly deep in the right breast, five centimetres from the midline (Figure 2). Meticulous dissection ensued, particularly at the site of the known tumor in the 3 o’clock position. The VP shunt was preserved and specimen sent for histology. The patient remained on IV antibiotics until the drains were removed due to the presence of the VP shunt. Medical records were obtained from another hospital which revealed the patient had undergone insertion of a VP shunt for relief of hydrocephalus secondary to the intracerebral hemorrhage. Final histology revealed diffuse DCIS in the left breast and two invasive grade 2 ER/PR + lobular in the right breast. The cancer in the 3 o’ clock position was 2 cm in size and present within 1.4 mm of the deep resection margin. The right SLN biopsy was positive for micrometastases. The patient had an unremarkable postoperative course and underwent four cycles of adjuvant (adriamycin, cyclophosphamide and paclitaxel). She was well with no signs of recurrence six months postoperatively and was commenced on hormonal therapy.

Figure 2: Discovery of the shunt catheter 5 cm from the midline. [left = cephalad, right = caudal]

DISCUSSION

Breast related VP shunt complications including; shunt migration, CSF pseudocyst, CSF ‘galactorrhea’ and shunt obstruction, are well documented in literature and represent a class of thoracic shunt complications [5]. To date however, only five cases of breast cancer adjacent to a ventriculoperitoneal shunt have been described. The most recent case reports on a 74-year-old patient with invasive ductal carcinoma encasing a VP shunt which, despite surgery, chemotherapy and radiotherapy, recurred on two occasions. The patient declined any further treatment or replacement of the shunt upon diagnosis of the latest recurrence [6]. Jain et al. described the case of a 67-year- old woman with a screen detected invasive carcinoma encircling a VP shunt which had been inserted following excision of an ependymoma. The VP shunt in this case had to be rerouted by the neurosurgeons during the wide local excision [7]. The third case describes a 70-year-old female who presented with neurological symptoms secondary to extrinsic VP shunt compression by a large breast mass. Intraoperatively, there was no identifiable flow distal to the breast mass and she underwent a modified radical Figure 1: Absence of ventriculoperitoneal shunt catheter on mammography. mastectomy with relocation of the VP catheter [8]. The

International Journal of Case Reports and Images, Vol. 6 No. 12, December 2015. ISSN – [0976-3198] Int J Case Rep Images 2015;6(12):763–766. Heaney et al. 765 www.ijcasereportsandimages.com fourth case from New York reports an 88-year-old patient ********* with advanced dementia with multicentric invasive lobular carcinoma. The presence of the VP shunt was Author Contributions only identified following review of her medical notes. Roisin M. Heaney – Substantial contributions to While a mastectomy was indicated, a decision to excise conception and design, Acquisition of data, Analysis only the mass around the VP catheter was made based on and interpretation of data, Drafting the article, Revising the patients multiple comorbidities and poor premorbid it critically for important intellectual content, Final status [9]. The earliest documented case in 2001 approval of the version to be published involved a 52-year-old who underwent a modified radical Patricia Cronin – Analysis and interpretation of data, mastectomy for a 5 cm invasive carcinoma. Review of Revising it critically for important intellectual content, her medical notes revealed insertion of a VP shunt for Final approval of the version to be published hydrocephalus secondary to an acoustic neuroma 5 years Maurice Stokes – Analysis and interpretation of data, previously. Intraoperatively, the shunt was identified 5 Revising it critically for important intellectual content, cm from the midline inside the mastectomy incision [10]. Final approval of the version to be published Extreme care and preoperative planning is essential in the management of invasive breast carcinoma involving a Guarantor VP shunt. In many cases, identifying the presence of a VP The corresponding author is the guarantor of submission. shunt may be difficult due to patient factors (dementia, forgetfulness, etc.) or incomplete medical notes. Failure Conflict of Interest to identify its presence can be further confounded by its Authors declare no conflict of interest. apparent absence on imaging studies, as happened in our case. Care must be taken to avoid iatrogenic Copyright to the VP catheter during investigation and work up of © 2015 Roisin M. Heaney et al. This article is distributed the cancer (fine needle aspiration or core biopsy) as well under the terms of Creative Commons Attribution as definitive management of the tumour. The location License which permits unrestricted use, distribution of the shunt in relation to the tumour may preclude and reproduction in any medium provided the original certain types of surgery or may require involvement of author(s) and original publisher are properly credited. the neurosurgical team for relocation of the shunt as Please see the copyright policy on the journal website for happened in cases two and three described above [7, 8]. more information. The possibility of seeding of tumor cells on the shunt catheter surface was raised by Copeland-Halperin et al. as their patient developed multiple recurrences despite REFERENCES adequate therapy [6]. When planning insertion of a VP shunt, neurosurgeons must give due consideration to the 1. Cancer in Ireland 2013: annual report of the National possibility of future oncological breast surgery and site Cancer Registry. National Cancer Registry, Cork the catheter accordingly [10]. Ireland. 2013. [Available at: http://www.ncri.ie/ Our case highlighted the importance of obtaining a publications/statistical-reports/cancer-ireland-2013- patient’s medical history as well as reviewing their medical annual-report-national-cancer-registry] 2. Pudenz RH. The surgical treatment of hydrocephalus- notes preoperatively. Without knowledge of its existence, -an historical review. Surg Neurol 1981 Jan;15(1):15– no neurosurgical opinion was sought perioperatively. 26. Meticulous dissection allowed for removal of the breast 3. Reddy GK, Bollam P, Shi R, Guthikonda B, tissue and preservation of the ventriculoperitoneal shunt Nanda A. Management of adult hydrocephalus catheter. with ventriculoperitoneal shunts: long-term single-institution experience. Neurosurgery 2011 Oct;69(4):774–80; discussion 780–1. CONCLUSION 4. Patwardhan RV, Nanda A. Implanted ventricular shunts in the United States: the billion-dollar-a- year cost of hydrocephalus treatment. Neurosurgery We report the case of a 75-year-old patient 2005;56(1):139–44; discussion 144–5. with invasive lobular carcinoma in which a 5. Schrot RJ, Ramos-Boudreau C, Boggan JE. Breast- ventriculoperitoneal shunt catheter was discovered related CSF shunt complications: literature review adjacent to the tumour intraoperatively. Our case with illustrative case. Breast J 2012 Sep;18(5):479– emphasises the importance of reviewing the patient’s 83. medical history on the morning of surgery. In addition 6. Copeland-Halperin LR, Cohen RA. Recurrent breast to this, neurosurgical team should be conscious of the cancer in a patient with a ventriculoperitoneal shunt. position of a ventriculoperitoneal (VP) shunt in female Case Rep Surg 2015;2015:659395. patients, taking into account the increasing incidence 7. Jain YK, Kokan JS. An interesting case of screen- detected breast cancer encasing a ventriculoperitoneal of breast cancer and the possible requirement of future shunt. 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International Journal of Case Reports and Images, Vol. 6 No. 12, December 2015. ISSN – [0976-3198] Int J Case Rep Images 2015;6(12):763–766. Heaney et al. 766 www.ijcasereportsandimages.com

8. Roka YB, Gupta R, Bajracharya A. Unusual cause for ventriculoperitoneal shunt failure: carcinoma breast compressing distal catheter. Neurol India 2010 Jul- Aug;58(4):662–4. 9. Lee D, Cutler B, Roberts S, Manghisi S, Ma AM. Multi- centric breast cancer involving a ventriculoperitoneal shunt. Breast J 2010 Nov-Dec;16(6):653–5. 10. Keshtgar MR, Ahmed AR, Baum M. Ventriculo- peritoneal shunt and breast carcinoma. Ann R Coll Surg Engl 2001 Jul;83(4):281–2.

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